Respiratory assessment

Heidi Simpson

Initial assessment
Abstract Middleton and Middleton (2002) state that
examination should begin by observing the
The ability to carry out and document a full respiratory assessment is an essential
skill for all nurses. The elements included are: an initial assessment, history patient from the end of the bed.The practitioner
taking, inspection, palpation, percussion, auscultation and further investigations. will assess the degree of breathlessness, distress,
A prompt initial assessment allows immediate evaluation of severity of illness and cyanosis, amount of supplemental oxygen and
appropriate treatment measures may warrant instigation at this point. Following speech pattern. Cyanosis is a dusky or bluish
this, a comprehensive patient history will be elicited. Clinical examination of the tinge to the skin (Cox, 2001). Peripheral
patient follows and involves inspection, palpation, percussion and auscultation. cyanosis results from vasoconstriction, reduced
At this point, consideration must be given to preparation of a light, warm, quiet, cardiac output or vascular occlusion (Cox, 2001)
private environment for examination and suitable patient positioning. Inspection is and is best observed at the peripheries and nail
a comprehensive visual assessment, while palpation involves using touch to gather beds. Central cyanosis occurs when there is an
information. The next stages are percussion and auscultation. While percussion is increased amount of haemoglobin not bound
striking the chest to determine the state of underlying tissues, auscultation entails to oxygen, and is best assessed by observing the
listening to and interpreting sound transmission through the chest wall via a oral mucosa, lips and tongue. Central cyanosis is
stethoscope. Finally, further investigations may be necessary to confirm or negate not usually clinically detectable until the arterial
suspected diagnoses. oxygen tension falls below 8 kPa (kilopascal) and
arterial oxygen saturations below 90% (Singh
Key words: Patient assessment n Respiratory system and disorders and Rees, 1997). However, in a patient with

P
ractitioners are faced with a range of
respiratory emergencies on a daily basis
(Steismayer, 1993). Cox and McGrath
(1999) assert that nurses must enhance
and expand their skills with regard to carrying out
and documenting a comprehensive respiratory
assessment. Following a thorough assessment,
potential or actual problems may be identified
and timely intervention instigated. Equally,
once treatment has commenced, effectiveness
must be evaluated with ongoing reassessment
(Middleton and Middleton, 2002).
A comprehensive respiratory assessment
requires that the practitioner has a good
understanding of the anatomy and physiology
of the respiratory system (Cox and McGrath,
1999). This allows comparison of patient
findings to those expected in a normal subject.
The reader should refer to anatomy and
physiology textbooks as there is not scope
within this article to provide this.
A respiratory assessment is best undertaken in
a systematic fashion and a number of approaches
Heidi Simpson is Senior Lecturer in Critical Care,
Kingston University and St George’s Hospital Medical
School, London
Accepted for publication: April 2006
have been advocated (Steismayer, 1993;
O’Hanlon-Nichols, 1998; Cox and McGrath,
1999; Jevon and Ewens, 2002).Whichever model
is followed, key elements of the assessment
remain the same: an initial assessment, taking
a patient history and inspection of the patient,
followed by an examination which includes:
palpation, percussion and auscultation. Finally,
other tests and investigations may be considered
to confirm or exclude diagnoses. Table 1 shows
the steps involved in a respiratory assessment.
Preparation of a suitable environment
Cox and McGrath (1999) note the importance
of suitable preparation before commencing a
respiratory assessment. This includes ensuring
that the environment is well lit, warm, quiet
and private. Positioning of the patient in
preparation for examination is also essential.
Bickley (2003) notes that the posterior chest
and lungs are best assessed with the patient in
the sitting position. The patient’s arms should
be folded across the chest with the hands
resting on opposite shoulders. The anterior
thorax and lungs are best assessed with the
patient in the supine position, particularly
when examining women as this position
allows breast tissue to be more discretely and
easily displaced.
anaemia, cyanosis may not always be obvious
as there is insufficient reduced haemoglobin
present (Singh and Rees, 1997).
Following the initial assessment, the
practitioner must note a set of vital observations
to include: temperature, heart rate, blood
pressure, respiratory rate, body weight and,
where possible, a haemoglobin measurement.
These initial observations will serve as a
baseline assessment and treatment plans may
be created based on these measurements. After
this initial assessment, it may be necessary to
commence treatment before a history and
further examination may be carried out. For
example, if a patient is clearly seen to be cyanotic
and breathless during the initial assessment,
high flow oxygen therapy will immediately be
commenced. Failure to do so could potentially
Table 1. Steps involved in
respiratory assessment
1. Initial assessment
2. History taking
3. Examination
• Inspection
• Palpation
• Percussion
• Auscultation
4. Further investigations

484 British Journal of Nursing, 2006, Vol 15, No 9


result in the patient becoming severely hypoxic
and proceeding to respiratory or cardiac arrest.
Patient history
Depending on the area where the practitioner
works, patient history may be elicited from
the patient or a relative directly, or from the
medical notes that accompany the patient.
For example, those working in accident and
emergency (A&E) departments will need to
possess excellent history-taking skills as previous
medical notes are unlikely to be available at the
time of patient presentation. For the practitioner
working within critical care or a general ward,
the patient may be unable to speak owing to
the level of respiratory embarrassment, or as
a result of being intubated and mechanically
ventilated.Therefore much of the history gained
will be from relatives or medical notes. Table 2
highlights areas that the assessor must focus
upon when taking a respiratory history.
Inspection
Inspection often begins with the hands.
Findings may include a fine tremor associated
with the use of high-dose bronchodilators
(Middleton and Middleton, 2002). Carbon
dioxide retention will also produce vasodilation
evidenced by warm, sweaty hands and an
irregular flapping tremor. Other signs to
note include nicotine staining and clubbing.
Clubbing is the abnormal enlargement,
thinning and alteration in the angle of the
finger and nail bases of either fingers or less
commonly, the toes (Cox, 2001). This usually
results from chronic hypoxia.
Inspection continues by assessing chest shape.
Normally the chest should be symmetrical
with the ribs descending at a 45° angle from
the spine (Middleton and Middleton, 2002).
The transverse (from side to side) diameter
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respiratory assessment
Table 2. Areas of focus
for a respiratory history
l Presenting complaint
l Present health
• Cough
• Shortness of breath
• Chest pain with breathing
l Past medical history
l Smoking history
l Environmental exposure
l Family health history
l Travel history
l Self-care behaviours
Adapted from: Jarvis (2004)
should be greater than the anteroposterior
(from back to front) diameter. Barrel shaped
chests (where the transverse diameter is equal
to the anteroposterior diameter) are commonly
seen in patients with chronic airflow limitation
(Epstein et al, 2004). In pectus excavatum
(funnel-shaped chest), the sternum is depressed
and in pectus carinatum (pigeon chest), the
sternum and costal cartilages project outwards
(Epstein et al, 2004). Kyphosis is forward
curvature of the spine and scoliosis is a lateral
curvature (Epstein et al, 2004). See Figure 1 for
illustration of these thorax configurations.
Breathing rate, depth and regularity should
be noted (Epstein et al, 2004). Normal
respiratory rate (eupnoea) is approximately 12
breaths per minute (Jevon and Ewens, 2002).
Inspiration is active and expiration passive
and the ratio of inspiration to expiration
is 1:2. During normal quiet breathing,
the main muscles used are the diaphragm
and the external intercostal muscles, but
when breathing becomes more difficult, the
accessory inspiratory muscles are employed.
Page 1
These include the sternomastoid, scalenes and
trapezii muscles.
All of the accessory inspiratory muscles
contract to increase the transverse and
anteroposterior diameters. The vertical
diameters are increased to a greater extent
by increased movement by the diaphragm.
Expiration is aided by active contraction of
the abdominal and internal intercostal muscles
(Middleton and Middleton, 2002). Breathing
should be symmetrical and rate should be
regular. Paradoxical movement can be seen
where some or the entire chest wall moves
inwards on inspiration and outwards on
expiration. This may occur as a result of a flail
chest where fractures of multiple ribs result
in a free section which moves independently
to the remainder of the chest (Cox, 2001)
(See Table 3).
Palpation
Palpation involves using the hands and fingers
to gather information (Cox and McGrath,
1999). Both hands are used to compare
right and left sides of the chest (Cox, 2001).
Furthermore, different parts of the hand are
used for different reasons: the palmar surface
and fingertips to assess size and shape of the
chest, the ulnar aspect and fingers to assess
vibration and the back of the hands to assess
temperature (Cox, 2001). The trachea should
be palpated to assess that it is in the midline.
This can be done by placing two fingers
either side of the trachea and judging whether
the distance between the sternomastoid
tendons and the trachea are equal on both
sides (Epstein et al, 2004). Tracheal deviation
indicates a mediastinal shift and may be
towards a collapsed or fibrosed lung or away
from a pneumothorax or pleural effusion
(Middleton and Middleton, 2002).
485
Figure 1. Illustrations of various shapes of the thorax. The second step in palpating the thorax
is checking for pulsations, tenderness,
depressions, bulges and paradoxical
movement (Cox, 2001). The thorax should
Normal adult Barrel chest
be systematically palpated, comparing left
Ant.
with right, starting above each clavicle and
Ant. continuing down the anterior chest, followed
by palpation of the posterior chest and each
axilla. Respiratory expansion (or excursion)
should be checked by standing behind the
Post. Post. patient and placing the thumbs next to one
another along the spinal processes at the
level of the 10th rib. The thumbs should
Ribs Chest wall is separate as the patient breathes in and return
Sternum held in a state of to their resting place upon expiration. A loss
“hyperinflation” of symmetry indicates a problem on one or
both sides of the thorax (Cox, 2001).
The final stage in palpation is tactile or vocal
fremitus, which is the palpable vibration of
the chest wall that occurs during speech (Cox,
Pectus excavatum Pectus carinatum
2001). Tactile fremitus is performed by placing
the edge or the flat of the hand on the chest
Ant. wall and asking the patient to say ‘ninety-
Ant. nine’ or count ‘one, two, three’. Vibrations are
transmitted through the lung tissue and felt
by the hand. In vocal resonance, the patient is
again asked to say ‘ninety-nine’ or count ‘one,
Post. two, three’ and the sound produced is listened
Post.
to by the practitioner through a stethoscope
Sternum Protrusion placed upon the chest wall. A decrease in
depressed of the fremitus either felt by touch (tactile fremitus)
into chest sternum or heard (vocal fremitus) may indicate air,
fluid or pleural thickening between the lung
and chest wall. The sound will be increased
or the vibrations felt will be greater if there
is consolidation, as sound transmission is
Table 3. Respiration patterns better through solid lung (Epstein et al, 2004).
Fremitus provides the most useful information
Pattern Description in areas where percussion is found to be
Tachypnoea Rapid shallow breathing rate > 24 breaths per minute. A normal response to abnormal (Singh and Rees, 1997).
fever, fear or exercise. Also caused by respiratory insufficiency, pneumonia,
alkalosis, pleurisy and lesions in the pons. Percussion
Bradypnoea Slow breathing < 10 breaths per minute. May be caused by drug induced Percussion of the chest causes the chest wall and
depression of the respiratory centre in the medulla, increased intracranial
underlying tissues to move. As a result, audible
pressure and diabetic coma.
Cheyne-Stokes A cycle in which respirations wax and wane in a regular pattern, increasing in sounds and palpable vibrations are produced
respiration rate and depth and then decreasing. Breathing patterns last 30–45 seconds (Bickley, 2003). Both hands should be used in
with periods of apnoea (20 seconds) alternating the cycle. Causes include severe performing this skill. One hand is placed on the
heart failure, renal failure, meningitis, drug overdose and increased intracranial chest with the fingers separated and the middle
pressure. May be normal in infants and the elderly in sleep. finger of the opposite hand is used as a hammer
Hyperventilation An increase in both rate and depth. Normally occurs in extreme exertion, fear to strike the interphalangeal joint of the middle
or anxiety. Also occurs with diabetic ketoacidosis, hepatic coma, salicylate
finger on the hand placed on the patient’s chest.
overdose, lesions of the midbrain and alteration in blood gas concentrations.
Hypoventilation An irregular, shallow pattern caused by an overdose of narcotics or anaesthetics.
Percussion should be performed systematically
May occur with prolonged bed rest or conscious splinting of the chest to avoid comparing left to right by moving down the
respiratory pain. chest at 3–4 cm intervals beginning above the
Biot's respiration A pattern with an irregular rate and depth. A series of respirations is followed clavicles (Rees, 2003). The loudness of the
by periods of apnoea. The cycle length lasts between 10 seconds and 1 minute. sound provides an indication of the density
Can be seen with head trauma, brain abscess, heat stroke, spinal meningitis and of the medium. A dense medium such as
encephalitis. consolidated tissue will sound quiet whereas air
Adapted from Jarvis (2004)
filled areas will sound loud (Cox, 2001).

486 British Journal of Nursing, 2006, Vol 15, No 9


Auscultation
Chest auscultation involves listening to and
interpreting the sounds transmitted through
the thorax by use of a stethoscope (Middleton
and Middleton, 2002). Rees (2003) notes that
the bell or diaphragm of the stethoscope can
be used in order to perform auscultation.
However, in clinical practice, the diaphragm is
normally used to listen to breath sounds while
the bell is best for listening to low frequency
sounds such as those produced by the heart
(Middleton and Middleton, 2002). Patients
who are self-ventilating should be asked to
breathe with an open mouth thereby increasing
tidal volume without causing hypocapnia and
extraneous upper airway noises often created
during nasal breathing (Rees, 2003).
A systematic approach must be followed to
allow comparison of the left and right sides
and the practitioner should listen through
both inspiration and expiration (Cox, 2001).
Furthermore, the anterior, posterior and
lateral aspects of the chest should be listened
to (Cox, 2001).
Normal breath sounds are created by airflow
in the trachea and large airways.They are heard
all over the chest wall throughout inspiration
and for a short while during expiration
(Middleton and Middleton, 2002).
Normal breath sounds are described as
vesicular, bronchovesicular and bronchial
breath sounds (Bickley, 2003; Jarvis, 2004).
n Vesicular breath sounds are soft and low
pitched. They are heard in inspiration and
continue without a pause through to about
one third of the way through expiration.
They are heard over most of the peripheral
lung fields where air flows through smaller
bronchioles and alveoli.
n Bronchovesicular sounds are heard in both
inspiration and expiration. These sounds
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respiratory assessment
Table 4. Sputum analysis
Description Causes
Saliva Clear watery fluid
Mucoid Opalescent or white Chronic bronchitis without infection, asthma
Mucopurulent Slightly discoloured but not frank pus Bronchiectasis, cystic fibrosis, pneumonia
Purulent Thick, viscous: yellow Haemophilus
Dark brown/green Pseudomonas
Rusty Pneumococcus, mycoplasma
Redcurrant jelly Klebsiella
Frothy Pink or white Pulmonary oedema
Haemophysis From blood specks to frank blood, Infecion (tuberculosis, bronchiectasis),
old blood (dark brown) infarction, carcinoma, vasculitis, trauma
also coagulation disorders, cardiac disease
Black Black specks in mucoid secretions Smoke inhalation (fires, tobacco, heroin),
coal dust
Source: Middleton and Middleton (2002)
are moderate in intensity and pitch and are heard in bronchitis and bronchiectasis and fine
mostly heard over major bronchi where fewer late inspiratory crackles occur are often heard
alveoli are located, posteriorly between the in pulmonary oedema and pulmonary fibrosis
scapulae and anteriorly around the sternum (Middleton and Middleton, 2002).
in the first and second intercostal spaces. Wheezes (previously called rhonchi) are
n Bronchial breath sounds are loud and high caused by flow through narrowed airways
pitched; these sounds are usually heard around (Rees, 2003). Any cause of narrowing including
the trachea and larynx. The expiratory phase bronchoconstriction, mucosal oedema, sputum
is longer than the inspiratory phase with a or foreign bodies may cause wheezes. The
short gap between the two phases. pitch of the wheeze gives an indication of
Adventitious sounds are abnormal breath the degree of narrowing so that high pitched
sounds that occur as a result of fluid accumulation, wheezes indicate near obstruction (Middleton
bronchoconstriction or an inflamed chest cavity and Middleton, 2002). Although wheezes may
lining (Cox, 2001). Adventitious sounds include occur following crackles in inspiration, they are
crackles, wheezes and pleural rubs. Crackles most usual in expiration when intrathoracic
(previously called crepitations or rales) are airways are narrow (Rees, 2003). Diffuse airways
clicking sounds heard during inspiration caused disease such as chronic obstructive pulmonary
by the opening of closed small airways during disease produces polyphonic wheezes (sounds
inspiration. Crackles are described as being composed of several harmonically unrelated
early, late, fine or coarse, localized or widespread. musical notes heard on a background of hissing).
Most crackles are inspiratory (Rees, 2003). Narrowing of a single large airway produces a
Coarse early inspiratory crackles are often monophonic wheeze (Rees, 2003).
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487
 A pleural rub is the creaking or rubbing Figure 2. Illustration of curvatures of the spine.
sound which occurs when the pleural surfaces
are roughened by inflammation, infection or
neoplasm (Middleton and Middleton, 2002).
Pleural rubs are heard equally over inspiration
and expiration. See Figure 2 for the locations
for percussion and auscultation of the anterior Scoliosis Kyphosis
and posterior chest.

Further investigations
Once the history has been taken and the clinical
examination performed, the practitioner will
have some idea of provisional diagnoses.
These may be confirmed or negated by
carrying out and obtaining the results of
tests. A simple test is to collect any sputum
the patient is able to produce and send this
off for microscopy culture and sensitivity
should infection to suspected. See Table 4
for information gained by observation of
sputum. Other useful investigations include:
spirometry, arterial blood gases, pulse
oximetry and chest radiography. Spirometric
tests include forced expiratory volume in
1 second (FEV1), forced vital capacity (FVC)
and peak expiratory flow (PEF). These look
at lung function and recorded values must once traditionally a medical role, the ability to Jarvis C (2004) Physical Examination and Health Assessment.
4th edn. Saunders, Philadelphia
be compared to normal values for individual undertake a clear, concise and systematic Jevon P, Ewens B (2002) Monitoring the Critically Ill Patient.
patients based upon age, sex, height and respiratory assessment is now an essential skill Blackwell Science, London
O’Hanlon-Nichols T (1998) The adult pulmonary system.
race (Middleton and Middleton, 2002). Pulse for all nurses in order that patients are treated Am J Nurs 98(2): 39–45
oximetry is a simple and non-invasive method quickly and appropriately.  BJN Middleton S, Middleton PG (2002) Assessment and
investigation of patients’ problems. In: Pryor JA, Prasad
of continually monitoring the amount of SA, eds. Physiotherapy for Respiratory and Cardiac problems.
haemoglobin saturated with oxygen (Jevon Bickley LS (2003) The thorax and lungs. In: Bates’ Guide 3rd edn. Churchill Livingstone, London
to Physical Examination and History Taking. 8th edn. Rees JP (2003) Respiratory diseases: symptoms and signs.
and Ewens, 2002). Whereas arterial blood Lippincott, Philadelphia Medicine 31(11): 1–7
gases provide important information with Cox CL, McGrath A (1999) Respiratory assessment in Simpson H (2004) Interpretation of arterial blood gases:
critical care units. Intensive Crit Care Nurs 15: 226–34 a clinical guide for nurses. Br J Nurs 13(9): 522–9
regard to adequacy of ventilation, oxygen Cox CL (2001) Respiratory assessment. In: Esmond G, ed. Singh S, Rees J (1997) Basics of respiratory medicine - 2.
delivery to the tissues and acid–base balance Respiratory Nursing. Balliere Tindall, London Examination. Student BMJ 5: 9–11
Epstein O, Perkin GD, Cookson J, deBono DP (2004) Pocket Stiesmeyer JK (1993) A four-step approach to pulmonary
(Simpson, 2004). Chest radiographs provide Guide to Clinical Examination. 3rd edn. Mosby, London assessment. Am J Nurs 93(8): 22–8
a clear picture of the extent and severity of
disease (Middleton and Middleton, 2002).
On completion of the respiratory assessment,
documentation must follow.This should include Key Points
the health history and examination findings. n Respiratory assessment involves: an initial assessment, history taking, inspection, palpation,
Deviations from normal and problems should percussion, auscultation and appropriate further investigations.
be identified and interventions evaluated and
n An initial assessment provides an immediate impression of severity of illness. Additionally
documented.
it is a useful baseline for measuring improvement or deterioration in condition.

Conclusion n Inspection of a patient is a comprehensive visual assessment.

A common misconception in clinical practice
is that a respiratory assessment involves just
noting respiratory rate and pulse oximetry
readings. However, successful treatment of a
patient with a respiratory complaint is dependent
on early detection of the underlying problem.
This may only be identified through a thorough
and systematic respiratory assessment that
includes: an initial assessment, inspection,
palpation, percussion, auscultation and carrying
out pertinent further investigations. Although
n Palpation involves using touch to gather information and is composed of four steps:
assessment of tracheal position, palpation of the thorax, checking for respiratory expansion
and tactile fremitus.
n Percussion is used to assess the state of tissues underlying the chest wall. Loud sounds
indicate the presence of air whereas quieter sounds are suggestive of consolidated tissue.
n Normal breath sounds are described as vesicular, bronchovesicular and bronchial.
Adventitious sounds include crackles, wheezes and pleural rubs.
n Further investigations such as assessment of sputum, blood gas analysis, pulse oximetry,
spirometry and chest radiography may be necessary to confirm a suspected diagnosis.

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